Nokea
A nurse in a community health center is assessing the results of the purified protein derivative (PPD) testing she performed to screen for tuberculosis (TB). She interprets which of the following results as positive for a 6-year-old client with no risk factors for TB?
- A. 4-mm erythema
- B. 5-mm induration
- C. 10-mm wheal
- D. 15-mm induration
Correct Answer: D
Rationale: The correct answer is D: 15-mm induration. In PPD testing, an induration (hardened raised area) of 15 mm or more is considered positive for TB in individuals with no risk factors. Choices A, B, and C are incorrect because an erythema of 4 mm, induration of 5 mm, or wheal of 10 mm are not indicative of a positive TB test result in a low-risk individual. Therefore, the interpretation of a 15-mm induration would lead the nurse to consider the test positive for TB in this case.
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A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?
- A. Pigeon
- B. Funnel
- C. Kyphotic
- D. Barrel
Correct Answer: D
Rationale: When assessing a client with COPD, the nurse should expect the client's chest to be barrel-shaped. This shape is a classic characteristic of COPD due to hyperinflation of the lungs. A 'Pigeon' chest shape is associated with pectus carinatum, a deformity of the chest wall. A 'Funnel' chest shape is seen in conditions like pectus excavatum. 'Kyphotic' refers to an exaggerated outward curvature of the thoracic spine. Therefore, the correct answer is 'Barrel' as it is the expected chest shape in clients with COPD.
A client hospitalized with deep vein thrombosis has been on IV heparin for 5 days. The provider prescribes oral warfarin (Coumadin) without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following is an appropriate nursing response?
- A. The Coumadin takes several days to work, so the IV heparin will be used until the Coumadin reaches a therapeutic level.
- B. I will call the provider to get a prescription for discontinuing the IV heparin today
- C. Both heparin and Coumadin work together to dissolve the clots.
- D. The IV heparin increases the effects of the Coumadin and decreases the length of your hospital stay.
Correct Answer: A
Rationale: The correct answer is, 'The Coumadin takes several days to work, so the IV heparin will be used until the Coumadin reaches a therapeutic level.' Warfarin (Coumadin) is an oral anticoagulant that takes time to reach its full effect, typically a few days. In the meantime, IV heparin is used to provide immediate anticoagulation until the Coumadin levels become therapeutic. Option B is incorrect because discontinuing the IV heparin abruptly without reaching a therapeutic level with Coumadin can increase the risk of clot formation. Option C is incorrect because heparin and Coumadin do not work together to dissolve clots; they both have anticoagulant effects but work differently. Option D is incorrect because IV heparin does not directly increase the effects of Coumadin; they have different mechanisms of action.
In preparation for the discharge of a client with peripheral arterial disease (PAD), the nurse should include which of the following instructions?
- A. Apply a heating pad on a low setting to help relieve leg pain.
- B. Adjust the thermostat so that the environment is warm.
- C. Wear antiembolic stockings during the day.
- D. Rest with the legs above heart level.
Correct Answer: D
Rationale: Resting with the legs above heart level is important for clients with peripheral arterial disease (PAD) to promote better circulation and reduce leg pain. Applying a heating pad on a low setting can actually worsen symptoms by causing burns or increasing blood flow to the area, which is not recommended for PAD. While keeping the environment warm is generally beneficial, it is not a specific instruction for managing PAD. Antiembolic stockings are typically used for preventing blood clots in hospitalized patients and may not be directly related to managing PAD at home.
A client comes to the emergency department reporting chest pain that is sharp, knife-like, and localized to an area he points to with one finger. The nurse should document this chest pain as which of the following?
- A. Angina pectoris
- B. Cardiogenic pain
- C. Myocardial infarction
- D. Pleuritic pain
Correct Answer: D
Rationale: The correct answer is 'Pleuritic pain.' Pleuritic pain is characterized by sharp, knife-like pain that worsens with deep breathing or coughing and is localized to a specific area. This type of pain is often associated with inflammation of the pleura. Choices A, B, and C are incorrect. Angina pectoris is a type of chest pain caused by reduced blood flow to the heart muscle. Cardiogenic pain refers to pain originating from the heart itself. Myocardial infarction is the medical term for a heart attack.
A client with angina pectoris is being taught about starting therapy with nitroglycerin (Nitrostat) tablets. The nurse should instruct the client to take the medication
- A. after each meal and at bedtime.
- B. every 15 minutes during an acute attack.
- C. at the first indication of chest pain.
- D. with 8 oz of water.
Correct Answer: C
Rationale: Nitroglycerin (Nitrostat) tablets are used to relieve chest pain associated with angina. The client should take the medication at the first indication of chest pain to help dilate blood vessels and improve blood flow to the heart muscle. Choice A is incorrect because nitroglycerin should not be scheduled after each meal or at bedtime. Choice B is incorrect as taking the medication every 15 minutes during an acute attack is excessive and not recommended. Choice D is incorrect because while it is important to take nitroglycerin with water, the timing of water intake is not as critical as taking the medication at the first sign of chest pain.